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Provider photo for Alice Cheng-Bennett

Alice Cheng-Bennett, MD

Ophthalmology

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Blowout Fracture

Introduction
An orbital blowout fracture is the term that your doctor may use to describe a fracture or broken bone of the floor of your bony eye socket. Blowout fractures are caused by blunt trauma to the eye or cheek and can occur as isolated injuries or in combination with fractures of the cheekbone or other bones of the face.

While most blowout fractures cause no long-term complications, orbital blowout fractures can result in an increased in an increased volume of the eye socket, and this may result in a sunken in appearance to the affected eye (a condition known as enophthalmos). A small amount of enophthalmos might not be noticeable but larger amounts can create a noticeable imbalance between the two eyes in which the affected eyeball may appear smaller or downwardly displaced compared to the unaffected eye. Orbital blowout fractures can also be associated with entrapment of the muscles that move the eye within the broken bones.  When these muscles become stuck within the fracture site, this may result in tethering that prohibits the upward movement of the eyeball, causing double vision (a condition also known as diplopia).

Surgical intervention is not always necessary, but when indicated, the goal of treatment is to maintain or restore the best possible function to the affected eye and maintain the cosmetic appearance to the area of injury.

Symptoms
Patients with an orbital blowout fracture may complain of double vision (especially when looking up), numbness, and pain or tingling over the cheek that extends down to the upper lip, teeth and gums. In addition, patients may complain of nosebleeds, eyelid swelling, and increased pain or prominence of the affected eye following nose blowing. There may be tenderness to the touch along the boney rim of the eye socket and in some instances a step-off or disruption in the contour of the orbital rim may be present.

Although the affected eye may appear sunken or smaller compared to the uninvolved eye immediately following an injury, this finding may not be obvious immediately following the injury due to surrounding eyelid swelling. In fact, the eye may actually bulge forward as a result of swelling or bleeding behind the eye. This swelling also may restrict extra ocular muscle motility, giving the impression that entrapment of the eye muscles has occurred within the floor defect even if no such entrapment is present.

Screening and Diagnosis
Your doctor will perform a complete eye examination to ensure that the eyeball itself has not been injured. If an orbital blowout fracture is suspected, your doctor may perform an exam to determine if there is entrapment of the muscles that move the eye within the fracture site. An x-ray or CT scan may be required to determine if a fracture is present and to provide information on the size of the break and whether or not the contents of the eye socket are entrapped within the fracture site. Any recommended therapy and the risks, benefits, and alternatives to treatment will be clearly explained.

Treatment Options
The occurrence of a blowout fracture in and of itself is not necessarily an indication for surgical repair. Patients without significant displacement of the eyeball within the boney eye socket or without entrapped muscle within the fracture site usually do not require surgical repair of the fracture. The hole in the floor of the eye socket will fill in with a layer of sturdy scar tissue in time. Patients with blowout fractures should be treated with oral antibiotics due to the disruption of the integrity of the eye socket and the surrounding sinus cavities. A short course of oral steroids may benefit the patient by reducing edema of the orbit and muscle. A “wait and see” approach may allow for an eventual more thorough assessment of the relative position of the eyeball compared to the uninvolved side and help to determine whether or not double vision is due to entrapment from the fracture versus double vision present from swelling of the soft tissues behind the eye. During the first few weeks after the occurrence of a blowout fracture, patients should avoid nose blowing which can cause air to pass from the sinuses into the eye socket (a condition known as orbital emphysema). Nasal decongestants may be used to keep the sinuses passageways open and allow for trapped old blood that can be a risk for infection to be cleared from the sinuses. If numbness of the cheek, lips, gum or teeth is present, this will usually resolve in time. Recovery of an injured sensory nerve may take as long as six months and is not usually an indication for surgical intervention.

Surgery
Surgery may be indicated if entrapment of an extra ocular muscle that serves to move the eye has occurred and is resulting in double vision.  Additionally a large fracture may be a risk for significant displacement in the resting position of the eyeball within the eye socket and can also be an indication for surgery.

The location of the blowout fracture can be reached through several different sites of initial surgical incision. The most common surgical incision is placed on the under surface of the lower eyelid of the involved eye in order to avoid a visible scar after surgery. Other potential sites of surgical incision include an incision within the skin of the lower eyelid, through an incision in the gum behind the upper lip or through an incision made behind the hairline, just above the ear.

Because the broken bone in a blowout fracture shatters into several small pieces, often some form of implant will be required to cover the hole in the floor of the eye socket. Several different types of implants are available for reconstructive use. Most orbital floor defects can be repaired with synthetic implants composed of porous polyethylene, silicone, metallic rigid mini-plates, synthetic mesh, metallic mesh or even your own bone.

As with any surgical procedure, bleeding, infection, and the need for additional surgery are risks for orbital blowout fracture repair. Possible loss of vision is the most ominous complication associated with blowout fracture repair, fortunately however, this is very rare. Persistent or new-onset double vision and new or persistent numbness and pain are also potential complications of blowout fracture repair. Implant extrusion and a residual sunken appearance of the eyeball are also possible in patients having undergone orbital blowout fracture repair in the past and may require additional surgical intervention.

The timing and requirements for surgical intervention in the repair of orbital blowout fractures will differ from patient to patient. Most surgeons will delay surgery for up to 2 weeks in order to allow for dissipation of swelling and pooled blood. This may allow your doctor to better assess the amount of enophthalmos present and whether double vision is due to entrapment or to swelling. However, too long of a delay in repairing a fracture may result in scarring of entrapped tissues that can reduce the chance of successful correction of double vision or enopthalmos. Of special note is the pediatric patient with an orbital floor fracture who has nausea, vomiting, and extraocular muscle dysfunction may require more urgent intervention.

If you have an emergency medical condition, call 911 or go to the nearest hospital. An emergency medical condition is any of the following: (1) a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in serious jeopardy to your health or body functions or organs; (2) active labor when there isn't enough time for safe transfer to a Plan hospital (or designated hospital) before delivery, or if transfer poses a threat to your (or your unborn child's) health and safety, or (3) a mental disorder that manifests itself by acute symptoms of sufficient severity such that either you are an immediate danger to yourself or others, or you are not immediately able to provide for, or use, food, shelter, or clothing, due to the mental disorder.

This information is not intended to diagnose health problems or to take the place of specific medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.

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